1. Imaging and Patient Selection
Mr Chris Roberts
Ipswich Hospital
Watanabe Club
York 2010

2. NB
• You must know
– How to take x-ray views
– What MRI sequences
– What CT views
• The result of the investigation must affect
patient management
• Don’t order an investigation for the sake of
it

3. Why investigate?
• Diagnosis
– Do we need to operate?
• Informed consent
• Patient planning
• List planning
– Positioning
– Timing

4. Which imaging modality?
• Likely diagnosis
• Cost
• Availability
• Access
• Expertise

5. Imaging modalities
• X-ray
• Ultrasound
• CT
• MRI
• Arthrography

6. Plain radiography
• AP shoulder
– Beam perpendicular to
body
– Commonest view
– Good view of ACJ
– Poor view of GHJ

7. Plain radiography
• AP GHJ
– Beam perpendicular to
scapula
– Good view GHJ
– Poor view ACJ

8. Plain radiography
• Scapular lateral
– Perpendicular to AP
GHJ view
– Conirms enlocation
GHJ
– Alignment for fractures

9. Plain radiography
• Outlet view
– As for scapular lateral
but beam tipped
caudally 10 degrees
– Acromial morphology
– Guide to
decompression
– Localise lesions

10. Plain radiography
• Axillary view
– Good view of GHJ
space
– Eccentric erosion
– Bone lesions
– Os acromiale

11. Plain radiography
• Modified axillary
views
– Post trauma

12. Plain radiography
• Bernageau view
– Anterior glenoid bone loss

13. MRI
• Imaging is performed in three planes
relative to glenohumeral joint
• Typical sequences
• Coronal oblique T1 and T2 spir
• Sagittal oblique T2
• Axial Watts (T2 fat suppressed)
• Axial T1 in instability
• Difficult for large patients – not central in
bore

14. MRI
• Coronal oblique
– Supra and
infraspinatus tendons
– Subacromial space
– A-C joint
– Superior labrum
– Biceps tendon
– Subscapularis

15. MRI
• Sagittal oblique
– Rotator cuff
• Tendons
• Muscle atrophy
– Acromial morphology
– Glenoid

16. MRI
• Axial plane
– Biceps tendon
– Glenoid labrum
• Bankart lesion
– Subscapularis
attachment

17. Common Pathology
• Rotator cuff disease
• Biceps tendon
• Glenoid labrum
• Bony lesion

18. Rotator Cuff
• Partial thickness
– Articular surface
– Bursal surface
• Full thickness
– Size
– Tendon retraction
– Muscle atrophy

19. Rotator Cuff

20. Rotator Cuff

21. Rotator Cuff

22. Bony Lesions

23. Instability
• Hill-Sach’s lesions
• Anterior labral tears –
Bankart lesion

24. Other lesions
• Cysts

25. MR arthrography
• Anterior labral lesions

26. MR arthrography
• SLAP lesion

27. MR arthrography
• HAGL lesion

28. CT scans
• Axial images
• Coronal and sagittal
reconstructions
relative to plane GHJ
• Quantifying bone
lesions

29. CT scans
• 3D reconstructions

30. Ultrasound
• Soft tissue imaging
– Coronal and sagittal
views
– SST, IST and SBSC
– Intratendinous lesions
– Muscle atrophy
– Not labrum
– Very user dependent
– Static images not very
useful

31. Ultrasound
• Cuff tears

32. Ultrasound
• Calcium

33. Ultrasound
• Effusions

34. Arthrography

35. How I image for cuff pathology
• Impingement
– Xrays: AP, outlet and axillary
• Impingement vs Sml cuff tear
– Add USS
• Large/massive cuff tear
– Add MRI

36. How I image for instability
• Atraumatic
– Xray AP shoulder
• Traumatic anterior
– Xrays: AP and Bernegeau
– If bone lesion or contact sportsperson add CT
• NB beware the HAGL

37. Case 1
• 43 y.o. female
• Painful arc
• Full movement
passively
• Cuff strong on testing

38. Case 2
• 55 y.o. man
• Painful arc, night pain
• No cuff wasting
• Full active movement
• Cuff painful and weak
on testing

39. Case 3
• 55 y.o. man
• Painful arc, night pain
• Cuff wasted
• Restricted active but
full passive range
• Cuff painful and weak
on testing
• Positive drop arm and
Hornblowers

40. Case 4
• 75 y.o. man
• Painful arc, night pain
• Cuff wasted
• Restricted active but
full passive range
• Cuff painful and weak
on testing
• Positive drop arm and
Hornblowers

41. Case 5
• 29 year old sedentary
worker
• 3rd traumatic anterior
shoulder dislocation
• No sports

42. Case 6
• 23 year
• 3rd traumatic anterior
shoulder dislocation
• Professional rugby
player